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Ideas and Opinions |

Alternative Perspectives on the Biased Foundations of Medical Technology Assessment

George A. Diamond, MD; and Timothy A. Denton, MD
[+] Article and Author Information

From Cedars-Sinai Medical Center and the School of Medicine, University of California, Los Angeles, California. Requests for Reprints: George A. Diamond, M.D., Division of Cardiology, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Los Angeles, CA 90048.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1993;118(6):455-464. doi:10.7326/0003-4819-118-6-199303150-00010
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Medical technology assessment seeks to improve the care of individual patients (the conventional unit of clinical practice) through evaluation studies conducted in groups of patients (the conventional unit of clinical investigation).This distinction between individuals and groups has practical relevance to the design, analysis, and clinical applicability of technology assessment studies. We define several biased perspectives about technology assessment that derive from the distinction between individuals and groups: a misguided emphasis on efficacy versus effectiveness, on statistical significance versus clinical importance, and on objective versus subjective outcomes. In each case, we contrast these alternative perspectives and speculate on their implications for health care policy.

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Grahic Jump Location
Figure 1.
Frequency distribution of benefit for each arm of the hypothetical DELI-2 trial (baloney compared with cabbage).

The area under each distribution represents 1000 patients. The shaded areas represent the raw distributions, and the curves represent the fitted theoretical (β) distributions. The gray bars represent patients who derived positive benefit, and the black bars represent patients who derived negative benefit. Note that the mean of the distribution on the left (0.340) is higher than that of the distribution on the right (0.240), whereas the gray region (representing positive benefit) for the distribution on the right (0.907) is larger than the corresponding gray region for the distribution on the left (0.817).

Grahic Jump Location

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